Dentistry/New crowns

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Question
Dear Dr Burnett!

I have read many of your answers here and very much appreciate what you say. Primum non noncere!

My present situation in my opinion unfortunately require a mayor treatment. I am in a cul de sac and I have to stop patching up ceramic crowns with composites.

I think I have to give you my background:
Many amalgam fillings as a child and teenager. I realized that I was bruxing in 1988 and then had already ground off a fair bit of my teeth. The bruxism problem was fixed perfectly with a Thanner brace 1989. 1991 I had many porcelain crowns when replacing amalgam fillings. The occlusion was not quite good after this. By 1995 I found that teeth 11 21 22 and 23 had worn down to the enamel. In 1996 the first tooth cracked and then it started getting worse as a domino effect (I believe).

As the occlusion was not good I asked my dentist if it was possible to build up the bite in the back so that I would not constantly have the contact in the front. In 1999 two mm onlays was put in on teeth 3-7 in upper jaw. It turned out a catastrophe. The bite was now far worse than before, the teeth meeting even more in the front. (During the occlusion adjustment I had told the dentist that I though he trimmed off too much in the back again. Hi did not listen. I certainly could tell better with the help of my senses, than the dentist could with his equipment, where to trim off.) Adding to that the onlays was nearly flat, virtually no cusps, so I had to chew really hard when eating. The onlays all fractured in a few years. In about five years most of the front teeth had fractured. In 15 years I have been having average 5-6 treatments every year mainly for fractured crowns and also some crowns coming off whole. Especially the front teeth.

Now the situation is so that my molars have no contact, some crowns are provisional and the upper jaw crowns are all in need of new crowns. Teeth 12 to 21 has a temporary bridge. In the lower jaw over 50 % need replacement and the wearing is uneven (Zirconium wearing on the softer Empress) so some teeth are a lot higher than other. 46 + 47 have composite fillings needing replacement and have no contact with opposite molars. 37 have two composite fillings. At night I wear a brace of three mm at the back (no contact in the front) and it works excellent. I think that now is the time to finally build up the bite in both jaws. I cannot see any other good solution that can last long. In fact the current mess is a golden opportunity as so many things need repair.  

(It is very difficult finding a dentist who like to build up the bite. In the 15 years I have asked many dentists and no one but one wanted to raise the bit more than with 1 mm. He, an occlusion specialist said: ”Spontaneously I think your bite could be raised 5 mm.” I think he meant in the front. I went to the highly respectable dentist that he recommended, who wanted to raise with 1 mm in the back. One recently wanted to do 1 mm in the upper jaw but nothing in the lower jaw but adjusting - which would get the bite down. I think that this is far from optimal. Currently at light contact there is only contact in the
front. The thickness of the front teeth where the lower teeth meet the upper in the front before I had the bridge was approx. 0.1-0.2 mm at the thinnest place on the old 11 crown just near the gingiva, the place where the 11 and 21 recently needed repair about 6 times in 6 months due to the difficult occlusion situation, before the temporary bridge was made).

My feeling is a rise of the bite with at least 2 mm, maybe 3 mm at the back is needed and that this may be good also for a minior TMJ problem - although I experience no real symptoms. Finally, on google I found Cosmetic Dentistry and Dawson. I found a dentist educated in both and being willing to build up the bite.

Now the plan is to build up the bite with composites until satisfaction is reached. Then replacing with I assume Zirconium crowns (some inlays) or/and Emax. I assume that in this way it is not necessary to remove anything, or perhaps just minimally from my own tooth substance.

(After 15 years of mental, dental-occlusal and economic suffering I would like to have a new life. I don’t want to make any new mistakes. What I do now will be very determinating for the teeth for the rest of my life, for my health, wellbeing and economy. This is why I ask.)   

Question 1: What do you think? Am I on the right track? Is there something I haven’t thought about? Is there anything I should think of to do or not to do when planning such a big matter? Should all materials be of the same kind? Can you have both Emax and Zirconium? Are there other better materials?

Q. 2: Tooth 11 is missing. The neighbors 12 and 21 are also crowned so no need to destroy virgin tooth substance for a bridge. Similar, one molar will also be removed. Of the neighbors one is crowned and the other will (likely) have an inlay mesially next to it (maybe a composite?). Which replacement would you recommend? Bridge, implant, some kind of sinle tooth replacement like butterfly or other? Is it a bad thing to ”lock” the 21 and 12 together? I don’t quite like that idea. The teeth should be able to move shouldn’t they, and a bridge would minimize that?

I much appreciate any comments you may have!

Ben

Answer
Dear Ben,

I appreciate your comments about you finding some of my writing useful here.  That is quite a compliment from someone as well informed as you are. Your understanding of your case is amazing.

First I want to say I have nothing to add to the clear information you presented.  I can assure you that you know more about the best way to treat your problem than 99% of the dentists you encounter.  You are in the later stages of the lifelong breakdown and repair of dental restorations.  Unfortunately your situation is made more unbearable and expensive by the malocclusion problem.  It sounds as if you are experiencing "the perfect storm" and I can only sympathize.

Your reference to "do no harm" makes me wonder if you would have been better off with less or no aggressive treatment of your malocclusion.

I hope you can find a wonderful dentist to help with this problem.  You will likely encounter the necessity of root canal work as the treatment proceeds.  It would be best to be under the care of a good do it all dentist rather than be bounced around between specialists.

Was recurrent decay around any of your previous crowns a problem?  If so, I have more advice about prevention in the future with a follow up.  I need to know something about your risk status however.  It would help to know if decay occurred around your previous crowns.

You have confirmed for me that the future of Medicine and Dentistry will undergo great change as people like you have access to information that wasn't previously available to the patient.  Dr.knows best will change.  People are more interested in finding out the details on the internet that were never before accessible, especially when it concerns their own serious case.

Larry Burnett DDS  

Dentistry

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Larry Burnett DDS

Expertise

Preventative Dentistry. Conservative Periodontal Therapy

Experience

National lecturer on conservative treatment of periodontal diseases and elimination of tooth decay. Former adjunct professor of oral microbiology at a Leading school of dental hygiene. Former investigator for State Board of Dentistry. Retired from private dental practice.

Organizations
ADA

Publications
RDH Magazine. Numerous articles

Education/Credentials
Graduate of Medical College of VA School of Dentistry. 20 years teaching hygienists at NOVA

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